A Partnership Model for Public Health

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A Partnership Model
for Public Health
www.coregroup.org
Five Variables for
Productive Collaboration
Child Survival Collaborations and Resources Group
www.pactpublications.com
Beryl Levinger, Ph.D.
Monterey Institute of International Studies
Jean Mulroy
Education Development Center, Inc.
July 2004
Pact Publications
1200 18th Street, NW, Suite 350
Washington, DC 20036
A Partnership Model for Public Health: Five Variables for Productive Collaboration
© Copyright 2004 Pact Publications
All Rights Reserved
First Printing/ June 2004
Library of Congress Control Number: 2004106507
ISBN 1-888753-390
Pact Publications
1200 18th Street, NW, Suite 350
Washington, DC 20036
www.pactpublications.com
Pact Publications is an integrated publishing house that facilitates the design, production and distribution of innovative and progressive development materials. We are committed to offering customers the most appropriate educational materials and training tools relevant to the ever-evolving field of international development.
This paper is based on research carried out by the Education Development Center, Inc., funded by
The CORE Group, Washington, DC. Publication was made possible through support provided by the
Bureau for Global Health, U.S. Agency for International Development, under Cooperative Agreement FAO-A00-98-00030. This paper does not necessarily represent the views or opinions of USAID.
The CORE Group
300 I Street NE, First Floor
Washington, DC 20002
Tel: 202.572.6330
Fax: 202.572.6481
www.coregroup.org
A Partnership Model
for Public Health
Five Variables for
Productive Collaboration
Child Survival Collaborations and Resources Group
Beryl Levinger, Ph.D.
Monterey Institute of International Studies
Jean Mulroy
Education Development Center, Inc.
July 2004
Acknowledgements
About The CORE Group
The CORE Group, established in 1997, is composed of 35 US-based NGOs that implement child survival and
child health programs throughout the developing world. The CORE Group strengthens local capacity on a global scale to measurably improve the health and well-being of children and women in developing countries
through collaborative NGO action and learning. CORE Group members serve a combined total of 250 million
women and children in over 140 countries.
The authors thank Karen LeBan, Executive Director, The CORE Group, for providing access to information and
documents, as well as all CORE members who agreed to be interviewed in the course of our research.
CORE Group Members
Adventist Development & Relief Agency
International Eye Foundation
African Medical and Research Foundation
International Rescue Committee
Africare
La Leche League International
Aga Khan Foundation, USA
Medical Care Development, Inc.
American Red Cross
Mercy Corps International
CARE International
Minnesota International Health Volunteers
Catholic Relief Services
Partners for Development
Christian Children's Fund
Program for Appropriate Technology in Health
Concern Worldwide USA
Pearl S. Buck International
Counterpart International, Inc.
PLAN International USA
Curamericas
Population Services International
Doctors of the World
Project Concern International
Food for the Hungry International
Project HOPE
Foundation of Compassionate American Samaritans
Salvation Army World Service Office
Freedom from Hunger
Save the Children
Health Alliance International
World Relief Corporation
Hellen Keller International
World Vision
Hesperian Foundation
i
Contents
Introduction ................................................................................................................. 1
Methods ..................................................................................................................... 3
Discussion: A Framework to Analyze Networking and Partnering Behaviors ............................... 5
CORE Group Case Study ................................................................................................. 9
CORE Group Polio Partners Project ........................................................................................................... 9
Positive Deviance/Hearth .......................................................................................................................... 11
C-IMCI Framework .................................................................................................................................... 12
Case Analysis ............................................................................................................ 15
Conclusions: Lessons for Partnering and Policy Implications ............................................... 17
References ............................................................................................................... 19
About the Authors
FIGURES
Figure 1: Public Health Partnership Analysis Framework Variables .................................................... 7
TABLES
Table 1: Analysis of CORE’s Critical Partnering Practices ................................................................ 15
ii
Acronyms
CBO
community-based organization
CGPP
Core Group Polio Partners
CORE
Child Survival Collaborations and Resources Group
IAF
Inter-American Foundation
IMCI
Integrated Management of Childhood Illness
LQAS
lot quality assurance sampling
MCH
maternal and child health
MDG
Millennium Development Goal
NGO
nongovernmental organization
OECD
Organisation for Economic Cooperation and Development
PAHO
Pan American Health Organization
PD
positive deviance
UNICEF
United Nations Children’s Fund
USAID
U.S. Agency for International Development
WHO
World Health Organization
iii
Summary
T
his paper presents a framework for assessing strategic partnering as a way to reach populations that
have been traditionally bypassed by maternal and child health (MCH) interventions. The framework is
applied to the Child Survival Collaborations and Resources (CORE) Group, a network of 35 U.S.-based nongovernmental organizations (NGOs) engaged in MCH activities. Concrete examples are given of how this partnership contributes to improved outcomes for mothers and children; enhanced policy dialogue; expanded local and
national capacity; and the generation of new resources. The paper concludes with the identification of relevant
lessons for MCH donors and NGOs that might wish to enter into similar partnership arrangements.
iv
Introduction
T
elecommunications professionals in the
North know that their technology’s full potential cannot be realized until the “last
mile barrier” is crossed. What is this elusive barrier
and why is it so hard to traverse?
ible boundary that separates “periphery” from “hinterland.”
There are two other striking parallels between the
“last mile barrier” issues of MCH and telecommunications specialists. In both worlds, the extension of
The answer lies in the bottleneck found on that
service coverage to “elusive” populations entails a
“last mile” of old copper phone lines that link indicompromise between affordability and “bandwidth”
viduals to ultra-modern fiber-optic networks. Such
(the potency of an intervention package). As well,
networks, capable of linking farprofessionals in both arenas pursue
flung locales, are relatively cheap
strategies that combine “hard” and
and simple to build in relation to the
“soft” sciences to achieve the holy
MATERNAL AND CHILD
coverage they provide. In contrast,
grail of universal coverage. The
HEALTH PRACTITIONERS
forging that critical connection be“soft” sciences include systematic
WORKING IN DEVELOPING
tween an actual end-user and the
and empirical thinking about such
COUNTRIES TODAY CONFRONT
nearest switch—usually not more
issues as social policy and investTHEIR OWN VERSION OF THE
than a mile away—is far more comment priorities, organizational ca“LAST MILE BARRIER.”
plex. Solutions for covering this fipacity development, grassroots
nal bit of terrain typically involve
coalition formation, and interpersignificant trade-offs between cost
sonal communication.
and service quality (e.g., bandwidth).
This paper describes in detail one approach, straMaternal and child health (MCH) practitioners
tegic partnering, that can be used to respond to the
working in developing countries today confront their
MCH “last mile” challenge. A framework for effecown version of this “last mile barrier.” Campaigns to
tive networking in the public health field is offered
immunize children against major vaccine-preventand then illustrated in the context of a case study
able diseases are, illustratively, analogous to fiberthat details the work of the Child Survival Collabooptic networks. Such campaigns link a network (the
ration and Resources (CORE) Group. The paper conHealth Ministry’s infrastructure) to switching stations
cludes with recommendations to public health
(clinics or health posts) in order to extend the
practitioners interested in launching or refining fieldnetwork’s coverage. Establishing these requisite linkbased inter-institutional partnering activities. We beages is often quite demanding. However, a far more
lieve the partnering model offered here has
daunting challenge lies in forging the necessary conwidespread applicability for public and private secnections between the clinic/switching station and
tor organizations working in developing countries to
those end-user households that lie beyond the invisimprove public health.
1
Methods
T
events, and open-ended interviewing) were used in
the current inquiry.
his study builds on three separate fieldbased investigations conducted by the authors on the impact of strategic partnering
for the rural poor in developing countries. Effects
considered largely relate to service coverage and the
expansion of favorable outcomes for vulnerable
populations. These studies were undertaken over a
period of three years, and each, in turn, will be
briefly described.
The third piece of research, carried out for the
World Bank in 2003, focused on partnerships between businesses and the Ministry of Education in El
Salvador (Tsukamoto et al. 2003). The aim of these
collaborative efforts was to improve education quality and coverage at the primary and secondary levels. Unlike the earlier two studies, this work was
The first, conducted for the Inter-American Founchiefly concerned with the policy-related implicadation (IAF), examined the experiences of 12 unretions of partnering rather than questions of service
lated grassroots developmentdelivery and extension of benefits to
oriented partnerships among nonunder- or unserved populations. The
governmental organizations
World Bank work enabled the reFIELDWORK CONDUCTED IN
(NGOs), local governments and, in
search team to develop methods for
FIVE LATIN AMERICAN
some cases, private sector businesses
relating partnering behaviors to
COUNTRIES YIELDED ROBUST
(Levinger and McLeod 2002). Fieldpolicies governing coverage and serINSIGHTS ON THE STAGES
work was conducted in five Latin
vice quality in relation to a single
AND TYPES OF PARTNERSHIPS
American countries. That study
sector (education).
AS WELL AS THE BENEFITS
yielded robust insights on the stages
The present study involved testAND BURDENS ASSOCIATED
and types of partnerships as well as
ing
conclusions drawn from the earWITH THESE RELATIONSHIPS.
the benefits and burdens associated
lier research in the context of a new
with these relationships. These insector (public health) and a broader
sights were used to create the framerange of geographic regions (Asia
work reported in this paper.
and Africa as well as Latin America). To do this, we
A second investigation, conducted for the United
applied the approach followed in the USAID study
States Agency for International Development (US(i.e., examining a single, multi-country network) and
AID), detailed the partnering practices and benefits
selected the CORE Group as the focus of this study.
of Katalysis, a Central American microfinance instiResearch techniques included interviews with
tutions affiliated with a single network (Levinger and
CORE partners; the use of participant-observer methMcLeod 2001). Fieldwork was carried out in three
ods at two of CORE’s annual meetings; a comprehencountries. Both the IAF and USAID studies included
sive review of program documents provided by CORE
interviews with representatives of partner institutions
partners (including project proposals, evaluations, and
and members of their beneficiary populations. The
“lessons learned” compilations); as well as interviews
methods developed for the USAID study (including
with leading edge public health practitioners familiar
thematic analysis of partner documentation, particiwith the field-based work of CORE members.
pant observation at formal and informal network
3
Discussion: A Framework to Analyze Networking
and Partnering Behaviors
Context
stantial gains, although sub-Saharan Africa appears
to have fallen further behind. Its current under-five
mortality rate is 170/1000.
Significant progress has been achieved in meeting
MCH goals in many developing countries. Illustratively, childhood immunizations against the major
vaccine-preventable diseases increased from less than
10 percent in the 1970s to nearly 75 percent in 2001
(UNICEF 2004).
Many MCH problems affect disproportionate
numbers of the rural poor. Illustratively, less than
half of rural children in the developing world receive
care for acute respiratory infection, a major cause of
infant and child mortality. In general, rural health
systems do not have adequate staff or resources to
meet the health needs of women and children.
(United Nations Development Programme 2003). A
recent developing country survey revealed that the
poorest 20 percent of the population always received
less than 20 percent of the benefits associated with
investments in public health. In countries with high
infant mortality rates, the bottom 20 percent account
for less than 10 percent of hospital use (United Nations Development Programme 2003).
Reported cases of polio fell by 99 percent during
the 1990s, and deaths caused by diarrheal disease
fell by half. With
regard to underfive child mortalSIGNIFICANT PROGRESS HAS
ity, 63 countries
BEEN ACHIEVED IN MEETING
achieved a oneMATERNAL AND CHILD
third reduction in
HEALTH GOALS IN MANY DEthis decade,
VELOPING COUNTRIES. FOR
while another
EXAMPLE, CHILDHOOD IMMU100 countries
NIZATIONS AGAINST THE MAachieved a oneJOR VACCINE-PREVENTABLE
fifth reduction in
DISEASES INCREASED FROM
this same meaLESS THAN 10 PERCENT IN
sure (UNICEF
THE 1970S TO NEARLY 75
2002).
PERCENT IN 2001.
To meet the MDGs associated with MCH, three
things must occur: (1) new approaches to reaching
traditionally bypassed and under-served populations
must be developed, tested, validated, and disseminated; (2) new institutional arrangements must be
created and tested to
expand access to
MCH services, parMANY MATERNAL AND CHILD
ticularly in rural arHEALTH PROBLEMS AFFECT
eas; and (3) a
DISPROPORTIONATE NUMBERS
supportive policy enOF THE RURAL POOR. LESS
vironment must be
THAN HALF OF RURAL CHILcreated. Strategic
DREN IN THE DEVELOPING
partnering, if done
WORLD RECEIVE CARE FOR
well, has the potenACUTE RESPIRATORY INFECtial to make contriTION, A MAJOR CAUSE OF INbutions to all three of
FANT AND CHILD MORTALITY.
these areas.
The Millennium Development Goals (MDGs), endorsed by the United Nations,
call for a reduction in maternal mortality by threequarters in 2015. To achieve this target, a great deal
of attention must be paid to sub-Saharan Africa where
half the developing world’s maternal deaths occur—
most in rural, outlying areas. Current data for that region suggest that one of every 100 live births
culminates in the mother’s death, and pregnant
women are 100 times more likely to die in pregnancy
and childbirth there than their counterparts in high-income Organisation for Economic Cooperation and
Development (OECD) countries, (United Nations Development Programme 2003).
The Framework
Another MDG proposes a two-thirds reduction in
child mortality. Most attention will be focused on
two priority areas, sub-Saharan Africa and South
Asia. During the past decade, South Asia made sub-
In earlier studies, the authors identified five sets of
variables that proved useful in analyzing partnership
behaviors and predicting partnership efficacy in expanding the quantity and quality of services avail5
A Partnership Model for Public Health
prising findings from the authors’ initial field research was that most successful partnerships do not
have formal hierarchical structures, nor are they generally bound by legal contracts (except in those instances where funds were to be jointly managed).
Instead, the high-functioning partnerships studied
were built on strong trust that ensured accountability
among participants. The openness of such arrangements enabled individual partners to flexibly draw
on the complementary skills present in the partnership, allowing each entity to make significant contributions to the common goal—even when
circumstances changed and new needs arose. Process
factors represent the minimum “relationship criteria”
that must be met for entities to form high performance partnerships.
able to traditionally bypassed groups. Each variable
set will be described briefly and then applied to the
CORE case.
The first variable set, activity domains, focuses
on the actual work of the partnership. The authors’
earlier field-based research identified five areas for
possible collaborative endeavors among partnering
institutions:
• Program Delivery: The direct provision to
beneficiaries of services linked to such
fundamental human needs as primary health care,
livelihood support (including credit), and basic
education.
• Human Resource Development: These activities
are designed to help individuals develop a deeper
awareness of community assets as well as the
skills and self-confidence needed to harness these
assets in pursuit of shared development goals.
Empowerment is usually an explicit goal of work
in this activity domain.
Value-adding
mechanisms comprise the third variable set. These
mechanisms can be
used to explain why
partnerships, at their
best, can accomplish
more than any individual actor in meeting the needs of
bypassed populations. Each of these
variables is briefly
set out below.
• Resource Mobilization: This is the process of
securing the financial and technical support
required to carry out activities in any of the other
domains.
• Research and Innovation: These are activities that
help local people and development practitioners
who work alongside them to test or assess new
ways of responding to priority needs and
problems. Work in this area is designed to yield
development breakthroughs.
ONE OF THE MOST SURPRISING FINDINGS FROM INITIAL
FIELD RESEARCH WAS THAT
MOST SUCCESSFUL PARTNERSHIPS DO NOT HAVE FORMAL
HIERARCHICAL STRUCTURES.
INSTEAD, RESEARCHERS
FOUND THAT HIGH-FUNCTIONING PARTNERSHIPS WERE BUILT
ON STRONG TRUST THAT ENSURED ACCOUNTABILITY.
• Continuity: Whenever partners create new
opportunities for the poor to maintain or expand
upon skills and competencies acquired through
earlier development initiatives, continuity is
achieved. Continuity entails planned efforts by
partners to consolidate development gains. Thus,
for example, a community that has engaged in
participatory planning and needs assessment
around one set of issues deepens those capacities
when it has the opportunity to assess and plan in
the context of new challenges.
• Public Information, Education, and Advocacy:
These activities generally build upon research and
field-based program delivery experience. Often,
there is a policy-oriented element to advocacy.
Mobilizing public awareness, campaigning on
behalf of policy reform, and advocating structural
changes in institutions that impact on the lives of
the poor are important components of this activity
domain.
The second variable set, process factors, describe
the way partners relate to one another. In earlier research, three process variables were deemed particularly important: commonality of goals (but not
necessarily methods), complementarity of experiences and resources, and trust. One of the most sur-
• Comprehensiveness: The more comprehensive an
intervention package, the greater the number of
causal factors it addresses.
• Coordination: Awareness of, and collaboration
with, other development actors in the community
6
allows partners to achieve better coverage,
develop more cost-effective programs, create
economies of scale and build social capital that
can be applied to future development challenges.
The fourth variable set is partnership type. In earlier studies the authors observed several different
phases of partnership development. It is important to
note that these phases need not occur in the sequence
presented below, and that it is not necessary for all
partnerships to pass through each of the following
phases. Furthermore, a given partnership may fluctuate between two phases (e.g., complementary and
synergistic partnership) as needs and resources
change or as evaluation activities give rise to program modification.
• Risk mitigation: All development projects face
threats to success. Partnerships mitigate (i.e.,
reduce or hedge) these risks, because such
arrangements lead to diversification of the actors’
skill sets, contacts, spheres of influence, and prior
experience. Thus, actors become better able to
respond to both internal weaknesses and those
related to design or management, as well as
external threats. The greater the diversity among
partners, the higher the risk mitigation potential of
the partnership.
• Potential partnership: Actors are aware of each
other but are not yet working closely together.
• Nascent partnership: Actors are partnering but the
partnership’s efficiency is not maximized.
Figure 1: Public Health Partnership Analysis Framework Variables
Pr
co oce
m ss
m fa
on c
go tor:
als
r
to
ac
sf
es ust
tr
oc
Pr
Private sector
actors
International
NGO actors
Information and
advocacy
:
Research and
innovation
National NGO
actors
Partnership Activity Domains
Human
resource
development
CBO Actors
National MoH
actors
Partnership type:
potential
Resource
mobilization
District-level
MOH actors
$+ ation
itig
km
Ris
Program
delivery
Local
community
$+ ity
inu
ont
Process factor:
complementarity
ss
$+ ivene
ens
reh
C
$+ tion
a
din
oor
C
Partnership type:
complementary
Partnership type:
synergistic
mp
Co
Partnership type:
nascent
Improved service coverage and expanded
benefits to traditionally bypassed groups
7
A Partnership Model for Public Health
• Complementary partnership: Partners derive
benefits and increased impact through greater
attention to a fixed and relatively limited set of
activity domains, generally program delivery and
resource mobilization.
such factors as complementarities of skills and resources, ease of coordination, and the principle of
“maximum tolerable unalikeness.” This principle is
a reflection of the idea that the more unalike partners
are, the greater the risk mitigation. Suitable actor
types include (but are not limited to) national and international NGOs; representatives from different levels of the Ministry of Health structure (national and
district levels, e.g.); business groups; communitybased organizations (CBOs); and other local community groups (both formal and informal).
• Synergistic partnership: Partners derive benefits
and increased impact by addressing complex,
systemic development problems through the
addition of new
activity
domains (e.g.,
AWARENESS OF, AND COLadvocacy and
LABORATION WITH, OTHER DEresearch).
VELOPMENT ACTORS IN THE
Figure One (see page 7), summarizes the five sets
of variables considered in the partnership analysis
framework presented thus far.
COMMUNITY ALLOWS PARTNERS TO ACHIEVE BETTER
When a develCOVERAGE, DEVELOP MORE
opment effort is
COST-EFFECTIVE PROGRAMS,
relatively straightCREATE ECONOMIES OF SCALE,
forward (i.e., few
AND BUILD SOCIAL CAPITAL.
causal factors and
proven technologies for addressing
them), complementary partnership may be the optimal arrangement. In contrast, when the development
problem is complex (i.e., multiple causal factors and
few technologies that are proven or affordable to address them), a synergistic partnership is likely to represent the preferred response. In analyzing a
partnership, it is useful to determine whether the
partnership type is well suited to the development
challenge the partnership is addressing.
Consistent with this model, the following five
questions provide a structure for predicting whether a
given MCH-focused set of actors is likely to achieve
more through joint rather than individual effort:
The final variable set to consider in partnership
analysis is actor types. In order to achieve maximum
risk mitigation, actor diversity is desirable. In general, the ideal mix of actor types is determined by
5. To what extent does the partnership create
conditions for sustainable improvements in public
health?
1. To what extent does the partnership mobilize
additional resources?
2. To what extent does the partnership organize
members according to their comparative
advantages?
3. To what extent does the partnership bring
promising innovations to new beneficiary groups?
4. To what extent does the partnership allow
beneficiary groups and partner organizations to
build on previous gains?
8
The CORE Group Case Study
THE CORE GROUP BEGAN ALMOST 20 YEARS AGO AS AN INFORMAL NETWORK OF CHILD SURVIVAL NGOS
WHO WANTED TO SHARE TECHNICAL INFORMATION AND LESSONS FROM THE FIELD. TODAY, CORE DEVELOPS
STATE-OF-THE-ART KNOWLEDGE AMONG ITS NGO MEMBERS, SYNTHESIZES NGO EXPERIENCES AND PROMOTES RECOMMENDED PRACTICES, AND FACILITATES LEARNING AND COLLECTIVE ACTION AMONG PUBLIC
HEALTH ACTORS.
Introducing CORE
board of directors selected from and elected by its
membership. Its current focus is on developing stateof-the-art knowledge, products, and collaborative services; serving as a communication link to synthesize
experiences and promote recommended practices; facilitating dialogue, learning and collective action
among public health actors; and advocating on global health policy issues.
The CORE Group is composed of 35 US-based
NGOs that implement programs to improve the
health of children and women throughout the developing world. These groups serve a combined total of
250 million women and children in over 140 countries. The founding organizations began their collaboration in 1985 when they participated in a series
of annual workshops for grantees sponsored by the
USAID Child Survival Program (Shanklin 2002).
These workshops exposed participants to the benefits
of sharing technical information and lessons learned
through field-based projects. In 1990 these NGOs began organizing to advocate for changes within
USAID’s child survival program. An informal entity
known as the Collaborative Group emerged from
these discussions.
An in-depth review of three CORE activities
Three specific examples of CORE’s MCH projects
are presented here to highlight features of the
partnership’s operations.
1. The CORE Group Polio Partners (CGPP)
Project
This effort targets potential polio victims in remote,
resistant, dangerous, and marginalized communities
that have not yet been reached by global eradication
efforts. A key strategic element of the approach entails working through CORE NGO members with
the strongest ties to target group communities and
the institutions that serve them.
In 1996, Collaborative Group members approached USAID with a request for financial support
to create a formal network. One year later, CORE
received its first grant. Its first workshop, held later
that year, was organized around thematic clusters
(e.g., Nutrition, Social and Behavioral Change).
These clusters later developed into the Working
Groups that form the nucleus of CORE’s technical
activities today (Shanklin 2002). This working group
structure allows CORE to capitalize on the strengths
and comparative advantages of members across technical areas.
CORE staff identified appropriate NGO members
and invited them to participate in the initiative
through the joint creation of project proposals that
reflected global and country polio eradication priorities. Participating NGOs were able to build on their
collective, diverse experiences in applying the technical package in multiple geographic regions. The proposals that met the program’s technical criteria were
bundled together to create a single, multi-country
program. This bundling model allowed smaller
NGOs to contribute to the joint effort while allowing
Over the last five years, the network has evolved
significantly as it has attracted new donor funds and
members. Its working groups on technical activities
and innovations have expanded. CORE now has a
small staff and a governance structure that includes a
9
A Partnership Model for Public Health
THE CORE GROUP POLIO
PARTNERS PROJECT CONDUCTS ITS WORK THROUGH
CORE NGO MEMBERS
WITH THE STRONGEST TIES TO
ducted social mobilization for supplemental immunization campaigns. Four country projects conducted
synchronized vaccination campaigns (CORE Group
Polio Partners 2002b, p. 8). Although the initiative
fell slightly short of its objective — seven new collaborative entities for the year — six of seven project
countries did establish local NGO consortia, which,
in turn, conducted technical and management training; mobilized demand for routine immunizations;
improved vaccine logistics systems; and encouraged
community contribution to delivery of
SIX OF SEVEN CORE POLIO
routine immunizaPROJECT COUNTRIES ESTABtions (CORE Group
LISHED LOCAL NGO CONPolio Partners 2002b
SORTIA, WHICH CONDUCT
pp. 3–5). The expeTECHNICAL AND MANAGErience also resulted
MENT
TRAINING; MOBILIZE
in key lessons about
DEMAND
FOR ROUTINE IMMUthe time needed to
NIZATIONS; IMPROVE VACCINE
establish trust
LOGISTICS SYSTEMS; AND ENamong partners, the
COURAGE
COMMUNITY CONimportance of a
TRIBUTION
TO DELIVERY OF
shared purpose, and
ROUTINE IMMUNIZATIONS.
the useful role that
“honest broker” organizations can play
(CORE Group Polio Partners 2002a).
each participating organization the opportunity to exercise its
unique expertise
(CORE Group Polio
Partners 2002a).
TARGET GROUP COMMUNITIES
The presence of a
CORE Secretariat reSERVE THEM. THE PRESENCE
mains an important
OF A CORE SECRETARIAT IS
element in building
AN IMPORTANT ELEMENT IN
trust among the partBUILDING TRUST AMONG PARTners and facilitating
NERS AND FACILITATING COORthe requisite coordiDINATION.
nation of efforts. The
combination of
bundled proposals
and centralized staff support has proven “synergistic
... having one without the other is less effective. The
Secretariat provides the shared goals necessary for a
bundled proposal and results-oriented collaboration.
Implementation by the consortium of activities described in the bundled proposal provides the shared
experiences, challenges and needs that provide direction and priorities for the Secretariat” (CORE Group
Polio Partners 2002a p. 13).
AND THE INSTITUTIONS THAT
Another important component of this initiative has
been the systematic introduction of technical innovations. One example is Lot Quality Assurance Sampling (LQAS), a rapid, simple statistical sampling
method that is used to draw important conclusions
from small samples and has proven valuable in assessing and selecting geographic areas for program coverage (Valadez, 1994). CORE members have not only
used the technique in projects but have also trained
personnel from NGOs and Ministries of Health in its
use. The sharing of information––particularly technical innovations such as LQAS––with local organizations and Ministries of Health has, according to
members, contributed to greater understanding of
childhood epidemiology at the local and national levels. Participating NGOs report improvements in program coverage, quality, and associated outcomes. The
health outcomes are well documented. Project beneficiaries number nearly 14 million under-five children
(CORE Group Polio Partners 2002a p. 1).
CGPP’s approach to achieving greater polio vaccination coverage in high-risk areas and hard-toreach populations entails strengthening local
capacity on a global scale. A key feature of the initiative is the coordination and mobilization of community involvement in mass oral polio vaccine
immunization campaigns. Local interventions incorporate seven critical components: building partnerships; strengthening existing immunization systems;
supporting supplemental immunization efforts; helping improve the timeliness of case detection and reporting; providing support to families with paralyzed
children; participating in national and regional certification activities; and improving documentation
(CORE Group Polio Partners 2002b, pp. 1–2).
In addition, the project takes into account the interrelationships between polio and other development
problems. Representatives of this CORE initiative participate in the Inter-Agency Coordinating Committee
for Immunization where they help to build bridges
among local-, country-, regional- and global-level ac-
In 2002, most of the seven projects linked to this
initiative supported planning; identified pockets of
low coverage; created local partnerships; and con10
PD/Hearth (PD/H) was developed over many years
by several applied nutritionists. Although the United
Nations Children’s Fund (UNICEF) funded research
into the methodology in the 1980s, the first formal
PD/H programs weren’t initiated until the early 1990s
in Bangladesh, Haiti, and Vietnam (CORE Group and
BASICS II 2000). In Vietnam, CORE member Save the
Children applied the approach to 14 communities.
Documented outcomes of PD/H include reductions in
the incidence of malnutrition and faster growth rates
among children. As PD/H proved successful in rehabilitating malnourished children, other NGOs became
interested, and SC began using the “Living University” as a dissemination tool. The Living University
uses engaging, interactive techniques to teach the
PD/H framework to managers and supervisors, who
in turn train volunteers to implement the program at
the community level.
tors. The strength and depth of the partnership allows
participating institutions to exert policy-level influence
that they would not have absent this collaboration.
2. Positive Deviance/Hearth
These are two public health methodologies with
broad applicability, which have been used with particular effectiveness in rehabilitating malnourished
children. CORE’s approach to promoting these methodologies will be examined in this section.
Positive Deviance (PD) is a strengths-based approach based on the theory that in many resourcepoor communities there are some families or
individuals who “employ uncommon, beneficial
practices that allow them and their children to have
better health as compared to their similarly impoverished neighbors.” PD practitioners seek to help communities understand these families’ or individuals’
practices and disseminate them
POSITIVE DEVIANCE IS BASED
throughout their
ON THE THEORY THAT, IN
communities. This
MANY RESOURCE-POOR COMis done by determinMUNITIES, THERE ARE SOME
ing a specific desirFAMILIES OR INDIVIDUALS WHO
able nutrition
“EMPLOY UNCOMMON, BENoutcome, identifyEFICIAL PRACTICES THAT ALing a few individuLOW THEM AND THEIR
als who have
CHILDREN TO HAVE BETTER
achieved the good
HEALTH AS COMPARED TO
outcome despite
THEIR SIMILARLY IMPOVERhigh risk, and then
ISHED NEIGHBORS.”
conducting a PD inquiry into the behaviors that explain
the good outcome. Behaviors that can readily be replicated by neighbors become the focal point of new
interventions designed to promote their broader
adoption (Marsh and Schroeder 2002).
The CORE Group’s involvement in the PD/H
methodology is on two parallel tracks: 14 CORE
member NGOs individually manage PD/H programs
around the world, and the CORE Nutrition Working
Group devotes significant resources to analyzing best
practices, formulating strategies and disseminating
information about PD/H techniques. Working Group
members meet regularly to discuss such technical
and implementation issues as monitoring and evaluation methods (CORE Group 2002a, pp. 21–22). Dissemination methods include the Living University,
manuals, studies, field visits, consultant visits, training for district and community program managers,
and training of trainers.
CORE’s role in global PD/H efforts exemplifies its
unique approach to scaling up the application of
promising approaches
that have been successfully demonstrated at
CORE’S ROLE IN GLOBAL
the local level. The
POSITIVE DEVIANCE/
group seeks to extend
HEARTH EFFORTS EXEMcoverage by conducting
PLIFIES ITS UNIQUE APoutreach to other actors
PROACH TO SCALING UP
who implement proTHE APPLICATION OF
grams. Outreach enPROMISING APPROACHES
tails training,
THAT HAVE BEEN SUCCESSadvocacy, knowledge
FULLY DEMONSTRATED AT
management, and techTHE LOCAL LEVEL.
nical support.
Hearth is an implementation strategy that mobilizes community volunteers and mothers or caregivers
of malnourished children to practice new health behaviors by bringing them together in a structured, safe
environment to learn new cooking, feeding, hygiene
and caring behaviors (CORE Group 2002a). Hearth
sessions usually consist of nutritional rehabilitation
and education over a 12-day period followed by home
visits (Nutrition Working Group, 2003).
11
A Partnership Model for Public Health
One of CORE’s key contributions in this area has
been its work on a descriptive IMCI implementation
framework based on members’ field experiences
(Winch et al. 2001). A key aspect of the framework
is Community Mobilization: “maximum community
leadership in the process of identifying, planning, organizing, and mobilizing resources for communitylevel health activities.” Organizations using the
framework are urged to promote community involvement in such tasks as identifying health needs and
priorities; community surveillance; and investigations into causes of child mortality (Child Survival
Technical Support Project, 2001). This emphasis on
community involvement supports an increased level
of sustainability in health efforts, thereby allowing
program outcomes to be maintained on the local
level. In addition, CORE and its membership have
been heavily involved in IMCI policy, planning, and
evaluation meetings at the local, regional, national
and international levels. These contacts have given
CORE the opportunity to disseminate communitybased perspectives to national and international
policymakers.
In 2003, CORE’s Nutrition Working Group released Positive Deviance/Hearth: A Resource Guide
for Sustainably Rehabilitating Malnourished Children. This comprehensive, field-oriented manual
enunciates the “essential elements” that are fundamental to any PD/H program.
3. The Community IMCI Framework
Integrated Management of Childhood Illness (IMCI),
a World Health Organization (WHO) and UNICEF
initiative launched in the early 1990s, aims to significantly reduce mortality and morbidity associated
with the five major causes of disease in children under five. Over the years, the program has been subdivided into three components: improving case
management skills of health workers; improving
health system support for high-quality care for children coming to health facilities or outreach sites; and
improving household and community practices related to child health, nutrition, and development.
CORE is primarily involved in activities related
to the third component, referred to as Household and
Community IMCI. CORE’s IMCI
The framework includes some
Working Group activities address
standard implementation procedures
CORE MEMBERS HAVE
policy and service delivery issues at
and a consensus-building process foHELPED DISTRICT- AND COMthe global and local levels. Globally,
cused on uniting diverse partners
MUNITY-LEVEL ACTORS INFLUthe CORE Working Group particiaround improving child health and
ENCE NATIONAL POLICY ON
pates in the official Interagency
nutrition at the district level (Child
HOUSEHOLD AND COMMUWorking Group (IAWG) charged by
Survival Technical Support Project
NITY INTEGRATED MANAGEWHO and UNICEF with guiding
2001). The framework groups IMCI
MENT OF CHILDHOOD
IMCI policy and overseeing early
implementation activities around
ILLNESS. MEMBERS HAVE ALSO
implementation (Winch et al. 2002).
three key linked requisite elements:
WORKED WITH MINISTRIES OF
At the regional level, CORE has
improving partnerships between
HEALTH TO ADAPT TECHNIworked with the Pan American
health facilities and the communities
CAL TOOLS FOR USE BY COMHealth Organization (PAHO) to test
they serve; increasing appropriate,
MUNITY HEALTH WORKERS.
technical tools and to formulate
accessible care and information
communication and behavioral
from community-based providers;
change strategies. At the national
and integrated promotion of key
level, CORE members have participated in advocacy
family practices critical for child health and nutritask forces to help district- and community-level action (Winch et al. 2001). The framework also stresses
tors influence national policy; have worked with
the importance of “optimizing a multi-sectoral platMinistries of Health to adapt technical tools for use
form.”
by community health workers; and have helped idenPractical application of the framework has led to
tify appropriate tools and practices for countries. At
improved
family and community practices in relathe district and community levels, CORE members
tion to all three elements. For example, with regard
have engaged with Ministries of Health and other loto strengthening the partnership between health facal actors (Child Survival Technical Support Project
cilities and the communities they serve, a CORE
2001).
12
member, Project HOPE, trained staff
at a local clinic in the Dominican
Republic in IMCI, which then used
the IMCI form and codes to record
information about children visiting
the clinic. The clinic’s community
outreach staff were also trained to
use the form to identify children
needing follow up visits. As a result
of the methodology, research found
significant increases in the proportion
of caretakers who brought their children back for follow up visits.
IN A 2001–2002 SURVEY,
CORE GROUP MEMBERS REPORTED THAT THE IMCI
FRAMEWORK HAD BEEN VALUABLE IN PROVIDING THEM
WITH A COMMON LANGUAGE
(Child Survival Technical Support
Project 2001). The framework proposes many ways in which NGOs
can collaborate with local governments and national Ministries in
multiple sectors.
In the CORE 2001–2002 member survey, respondents reported
RENT ACTIVITIES AND EXthat the Framework had been valuPLAINING HOUSEHOLD AND
able in providing them with a comCOMMUNITY IMCI TO OUTmon language for describing their
SIDE ACTORS.
current activities and explaining
HH/C IMCI to outside actors, disAnother key element of the framecussing child health issues with
work is the Multi-Sectoral Platform, an explicit effort
Ministries of Health and other collaborators, designby the IMCI community to “think and work beyond
ing interventions to address specific situations, and
the health sector” (Child Survival Technical Support
articulating an overall vision for community-based
Project 2001). The Platform “focuses on innovative
child health work (Winch et al. 2002). In an internal
strategies for linking broader development activities
survey of CORE members, 79 percent of respondents
with child health and nutrition,” based on the prinreported using CORE-supported materials in impleciple that “people may find it difficult or impossible
mentation of IMCI, and each of them had, in turn,
to adopt new [health promoting] behaviors if other
trained approximately four to five other organizaproblems that they face, such as food insecurity or
tions in the methodology (CORE Group 2002b p.
lack of access to clean water, are not also addressed”
22).
FOR DESCRIBING THEIR CUR-
13
Case Analysis
T
he CORE case, in many respects, represents
“best partnership practice” in terms of the
five sets of variables presented earlier. Furthermore, the case illustrates that innovative, synergistic partnerships can make a significant contribu-
tion in improving the coverage and quality of MCH
services, particularly with respect to the “last mile”
populations of rural sub-Saharan Africa and Asia.
Table 1 summarizes the case in terms of the key
partnering variables.
Table 1: Analysis of CORE’s Critical Partnering Practices
Activity
domains
Program delivery
Substantial
involvement in fieldbased service
provision woven
into major
initiatives
Human resource
development
Emphasis placed
on community
empowerment,
local skillsbuilding, and
policy-oriented
training
Resource
mobilization
Practice of “bundling” proposals
and working jointly
to secure funds
resulted in substantial in-flows of new
resources
Research and
innovation
Emphasis given to
bringing promising
innovations to scale
and to refining
internationally
accepted methodologies
Information and
advocacy
Significant attention
given to documentation of lessons
learned and
participation in
policy-setting bodies
Partnership
type
Initial contact among founding members at USAID Child Survival workshop illustrated a potential
partnership that entered into the nascent phase when the Collaborative Group was established. The three
initiatives presented here represent synergistic partnership as there is significant activity in all five activity
domains. This partnership is probably most appropriate for reaching “last mile” populations.
Actors
CORE strengthens linkages among US-based NGOs. However, it also gives significant attention to the
development and strengthening of linkages with the international MCH community; national and districtlevel ministerial personnel; community actors; and, through the in-country collaborative groups established
in support of the initiatives described, national organizations. Thus far, little outreach is observed to the
private sector.
Process
factors
Common goals
Trust
Complementarity
Members share a
strong commitment
to local empowerment and community-based
approaches to
MCH. A mission
statement sets forth
the group’s shared
goals and vision.
CORE members began working
together 20 years ago. The shift from
informal to formal network took five
years. This time was a vital investment,
since member NGOs often compete for
USAID and other funds and therefore
might view one other as competitors.
CORE’s policy of transparency in
decision-making allowed members to
build personal relationships and trust in
one another, and to establish a culture
of collaboration on CORE projects
regardless of their competitive stance vis
a vis other activities.
CORE’s members have different but
complementary resources, strengths and
experiences. Illustratively, some members
have strong technical skills in a particular
methodology, but, because of factors
related to size and history, do not have the
capacity to scale-up promising innovations
on their own. Other members have
significant ties and presence in traditionally
bypassed or under-served communities but
lack the technical capacity to introduce
promising new MCH methodologies to
communities they serve.
Risk mitigation
Diversity of partners’
Value-adding experiences, resources,
mechanisms networks, and roles
reduces risks to project
activities associated with
inadequate design or
changes in the external
environment.
Impact on
service
coverage
and quality
Continuity
Comprehensiveness
Coordination
In most instances,
CORE activities
built upon earlier
development
initiatives serving
the same
populations.
All 3 initiatives involve
a rich intervention
package that includes
community mobilization, local capacity
building, direct service
delivery, and the
forging of new institutional linkages.
CORE initiatives demonstrate
multiple mechanisms to promote
coordination at national and
international levels. These include
Working Group meetings,
publications, and in-country task
forces. CORE secretariat staff play
an important role in stimulating
timely and useful partner
communication.
All 3 initiatives have a distinct impact on extending service coverage and quality. This is accomplished in
two ways: through direct service provision to typically bypassed populations, and through “indirect
scaling,” which entails systematic outreach, training, and information dissemination to potential
replicators.
15
Conclusions: Lessons for Partnering and Policy Implications
T
here are many replicable elements of the
CORE model. For a partnership to have
added value, it must demonstrate its ability
to mobilize resources; organize members according
to their comparative advantages; bring promising innovations to new beneficiary groups; allow members
to build on previous gains; and create conditions for
sustainable improvements in public health. These
tasks can be readily accomplished if sufficient attention is paid to the five sets of partnership variables
outlined in this article.
Black et al. (1993) argue that the key to saving
children’s lives is not technological innovation but effective management of the knowledge that is already
available. Effective partnerships along the lines of
the CORE model could play an important role in this
area.
Successful replication by other organizational
public health actors will, however, depend on five
critical factors:
• the development of mechanisms that foster
simultaneous outreach to local, traditionally
bypassed communities and the health sector
“influentials” who set global and national
priorities;
Some of the details of CORE’s partnership model
deserve particular mention, because they can be readily
replicated and confer significant advantages. The division of labor within
the partnership between a secretariat
SYNERGISTIC PARTNERSHIPS
and thematically foCAN MAKE A SIGNIFICANT
cused working
CONTRIBUTION IN IMPROVING
groups facilitates the
THE COVERAGE AND QUALITY
organization of
OF MATERNAL AND CHILD
members according
HEALTH SERVICES, PARTICUto their comparative
LARLY WITH RESPECT TO THE
advantages.
“LAST MILE” POPULATIONS OF
• the ability to perform the reconnaissance required
to identify promising innovations that are ready
for scale-up;
• the ability to access funds to cover the costs of a
Secretariat;
• the ability to strike a suitable balance between
service provision to beneficiary groups (an
external focus) and activities that build member
capacity (an internal focus); and
RURAL SUB-SAHARAN AFRICA
CORE’s policy
of openly sharing
technical innovations allows for
promising methodologies to be introduced and replicated more rapidly than is generally the case with
“pilot” or demonstration projects. The partnership’s
strong emphasis on disseminating effective MCH
tools and methods along with its culture of trust have
also allowed members to build on previous gains. Finally, CORE’s wide range of relationships at the local, district, national and international levels provide
an opportunity for it to influence policy and shape a
context conducive to sustainable improvements in
MCH outcomes.
AND ASIA.
• the ability to allow the partnership to evolve at a
pace that is appropriate for building trust and
cohesion.
Bilateral and multilateral support for strategic
partnering is likely to be a cost-effective investment
in securing the well being of bypassed mothers and
children if these five elements are in place and if prospective partners are committed to paying close attention to the five sets of partnership variables
discussed earlier. If these conditions prevail, strategic
partnering will one day be considered as critical to
good outcomes for mothers and children as “growth
charting.”
17
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19
About the Authors
Jean Mulroy is a project manager and lead researcher at the Center for Organizational Learning
and Development, within the Education Development Center, an applied research and development
organization based in Newton, Massachusetts.
Among other activities, she designs and researches
partnership and its effects on organizational capacity
for U.S. and international NGOs. She holds a B.A. in
anthropology from Yale University and an M.A. in
international public administration from the
Monterey Institute of International Studies.
Beryl Levinger’s academic focus is the evaluation
and management of international nongovernmental
organizations, particularly those engaged in sustainable development. Dr. Levinger holds the position of
Distinguished Professor of Nonprofit Management at
the Monterey Institute of International Studies. Additionally, she heads the Center for Organizational
Learning and Development, a team specializing in
assisting international NGOs, foundations and development agencies with partnerships that respond to
populations in need. In a typical year, she works
with approximately 50 NGOs, government agencies
and multilateral institutions to assess and strengthen
institutional capacity. Additionally, during her more
than 30 years in nonprofit management and international education, she has held leadership positions
with the American Field Service Intercultural Programs, CARE and InterAction.
Please direct correspondence to:
Dr. Beryl Levinger
Distinguished Professor of Nonprofit Management
Graduate School of International Policy Studies
Monterey Institute of International Studies
185 San Remo Rd.
Carmel, CA 93923
Email: blevinger@miis.edu
21
A Partnership Model
for Public Health
www.coregroup.org
Five Variables for
Productive Collaboration
Child Survival Collaborations and Resources Group
www.pactpublications.com
Beryl Levinger, Ph.D.
Monterey Institute of International Studies
Jean Mulroy
Education Development Center, Inc.
July 2004
Pact Publications
1200 18th Street, NW, Suite 350
Washington, DC 20036
A Partnership Model for Public Health: Five Variables for Productive Collaboration
© Copyright 2004 Pact Publications
All Rights Reserved
First Printing/ June 2004
Library of Congress Control Number: 2004106507
ISBN 1-888753-390
Pact Publications
1200 18th Street, NW, Suite 350
Washington, DC 20036
www.pactpublications.com
Pact Publications is an integrated publishing house that facilitates the design, production and distribution of innovative and progressive development materials. We are committed to offering customers the most appropriate educational materials and training tools relevant to the ever-evolving field of international development.
This paper is based on research carried out by the Education Development Center, Inc., funded by
The CORE Group, Washington, DC. Publication was made possible through support provided by the
Bureau for Global Health, U.S. Agency for International Development, under Cooperative Agreement FAO-A00-98-00030. This paper does not necessarily represent the views or opinions of USAID.
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